McKinzie Approach

Question 1

Which category in Treatment Based Classification does the McKenzie approach fall into?

Answer 1

Specific Exercise Category

Question 2

What is centralization? What is the positive likelihood ratio of a disc lesion with + centralization?

Answer 2

distal pain in legs or elsewhere moves closer to the spinal cord. LBP may increase, but is considered a + sign. +LR = 2.8

Question 3

Does the nucleus pulposus move directionally with flexion and extension?

Answer 3

Yes, 2 studies confirm.

Question 4

What are the 3 syndromes in the McKenzie approach?

Answer 4

1) Postural
2) Dysfunction
3) Derangement

Question 5

Explain the postural type syndrome.

Answer 5

pain originates from habitually bad posture or static positions where prolonged end-range stress fires nociceptors (Paris calls this “the ligamentous ache”)

Question 6

Explain the dysfunction type syndrome.

Answer 6

occurs typically 8-12 weeks after a trauma or derangement, due to adaptive soft tissue shortening & scar tissue formation due to guarding movements. Can also be a progression of postural habits

Question 7

Explain the Derangement type syndrome.

Answer 7

used to classify symptoms & clinical signs; “reducible” or “irreducible”; due to trauma, sneezing/coughing, or insidious progression of postures/activities

Question 8

What are the main characteristics of the postural type syndrome?

Answer 8

-intermittent pain related to long duration in a static-posture, and relieved by posture changes.
-involves normal tissue
-no radiating or referred pain
-no ROM loss
treat–> with education about posture and treat impairments

Question 9

Name some characteristics of the dysfunction syndrome.

Answer 9

intermittent pain, only occurs at end-range movement when shortened tissue is stretched (ERP); always includes a loss of ROM; pain will not centralize or peripheralize with movement.

Question 10

How do you treat the dysfunction syndrome?

Answer 10

Apply self-generated stretching into painful/restricted ROM with low intensity, high frequency repetitions (10 reps, 4-6x/day); exercises should produce symptoms that subside 10-20 minutes after. If unsuccessful in pain relief & increasing ROM, PT-generated forces can by used. Educate clients on posture & body mechanics issues & the possibility of progression to derangement

Question 11

what is an adherent nerve root

Answer 11

Same causes of dysfunction in which the scar tissue binds a nerve root in the IV foramen

Question 12

how do you identify an adherent nerve root?

Answer 12

Identified with neurodynamic testing & movement exam (example: standing flexion is restricted, lying flexion & extension have no ROM loss). May see a deviation to the ipsilateral side of the adhesion

Question 13

How do you treat an adherent nerve root?

Answer 13

exercises to remodel tissue, as noted earlier; begin with FIL x 1 wk to ensure no derangement is present, then begin FIS every 2 hours, 10-15 reps. Always follow with extension exercises to prevent a derangement

Question 14

Why should a patient with an adherent nerve root not do flexion exercises before noon?

Answer 14

The discs are fuller in the morning and flexion will therefore cause more strain on the nerve root.

Question 15

What are characteristics of the Derangement syndrome?

Answer 15

constant or intermittent; always involves a loss of ROM in 1 direction; symptoms respond to repeated movements if reducible; symptoms can be local, referred, or radiating into the buttock or LE; often have +neuro signs

Question 16

How do you treat the derangement type syndrome?

Answer 16

Find the directional preference & treat it to centralize symptoms, progressively remodel tissue & educate patient as noted previously (posture & body mechanics stressed & absolute avoidance of peripheralizing direction)

Question 17

How would you progress a patient with the derangement type syndrome?

Answer 17

10 reps, 4-6x/day
Typically, the patient will achieve full ROM over time
As symptoms stabilize, decrease frequency to 2-4x/day
After 5-7 days without peripheralization/leg symptoms, introduce unloaded peripherlizing movement followed immediately by centralizing forces (caveat: never do flexion exercises before noon). Start with 1, then 5-6 reps before progressing to 10 reps & monitor response for peripheralization.
Extension should be continued 2x/day, flexion 1x/day x 6 weeks
Finally, patients should do exercises 1-2x/day for the rest of their lives prophylactically

Question 18

What condition would the Williams exercises (supine lumbar flexion) benefit?

Answer 18

stenosis

Question 19

If your patient does not get a response from doing 20 extension repetitions, should you have them keep going?

Answer 19

yes, sometimes it takes 50-100 repetitions

Question 20

What can you do if the symptoms don’t get better or worse with patient generated movements?

Answer 20

Can apply overpressure (yellow light, proceed with caution). Can do manipulations, mobilizations, belt/sheet.

Question 21

When would you use the lateral compartment/extension principle?

Answer 21

Indicated for posterolateral derangements not responding to sagittal plane movements
Symptoms are unilateral or asymmetrical

Question 22

What is done in the lateral compartment/extension principle treatment?

Answer 22

Move the hips away from the side of pain (repeated sidebending)
Retry the extension exercises
Can be done in loaded or unloaded positions

Question 23

If patient has a “hot disc”, too painful to do flexion/extension, what can you do?

Answer 23

May need to begin with prone lying over multiple pillows
Given time, can begin to remove pillows as long as gaining motion & not peripheralizing. This may be day 1 treatment!
Prone lying allows gravity to move nuclear material in a disc anteriorly; discs get 80% of their nutrition in the 1st hour of rest (unloading)
Can also address muscle tension, modalities, etc.

Question 24

what are signs of an irreducible derangement?

Answer 24

Failure to respond favorably to the movement tests (constant sciatica, all movements cause increase in radiating pain and no position can be found to provide lasting relief)
Signs of neurological involvement

Question 25

What can you do for an irreducible derangement?

Answer 25

treat under “traction group” classification.

Question 26

How are lateral shifts named, and what is the treatment?

Answer 26

Named for the side the shoulders are moved to

When correcting, always overcorrect them & then bring them back to neutral; finish with extension exercises.

Question 27

Name some keys to differentially diagnosing the 3 syndrome types.

Answer 27

Postural: Time factor involved with pain in static/prolonged positions; ROM normal
Dysfunction: Must be chronic; pain intermittent; ERP only with a loss of ROM in at least 1 direction
Derangement: Pain may be constant ; may demonstrate + Neuro signs (diminished DTRs, sensory changes, +dural signs, myotomal pattern weakness); will have PWM